Provider Demographics
NPI:1477942597
Name:OSEITUTU-EBANKS, NANNA (MD)
Entity Type:Individual
Prefix:
First Name:NANNA
Middle Name:
Last Name:OSEITUTU-EBANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3701
Mailing Address - Country:US
Mailing Address - Phone:347-743-3773
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE STE 151
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3761
Practice Address - Country:US
Practice Address - Phone:646-838-3560
Practice Address - Fax:646-838-3569
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04252315Medicaid